Paper for Discussion

Discussion Abstract

Normally the human immune system does not respond to molecules such as nicotine and cocaine. However, vaccines are under development that would generate a long-lasting natural immune response to a given molecule. This immune response makes the molecule incapable (or less capable) of passing the blood-brain barrier and thus not psychoactive in the vaccinated person. A vaccine against an addictive drug could be administered to addicts to aid in recovery or reduce the chance of relapse. If a vaccine were sufficiently permanent, it could also be administered in childhood or infancy as prophylaxis against the use of a drug with abuse or addiction potential. While vaccines like these are not available at present, they are a realistic possibility. As such, ethical questions raised by their potential use are worth considering.

1. If an anti-drug vaccine were sufficiently permanent it would have potential as a prophylactic against abuse or addiction. However, such a vaccine also brings ethical issues.

Some drugs with abuse or addiction potential also have therapeutic potential. Opiates are the most obvious example. Vaccinating against some or all opiates may cut a person off from critical therapeutic tools later in life. Even for drugs with no therapeutic potential, we could be barring doors we do not know exist yet as therapeutic applications can develop unforeseeably, possibly much later in a person's lifetime.

2. Ethical issues especially arise if we administer a permanent anti-drug vaccine in childhood or infancy when the patient cannot make his own informed choice.

A common concern with anti-drug vaccines is that they reduce but do not eliminate the drug passing the blood-brain barrier. Thus, a user might just increase his consumption to compensate, possibly increasing overall harms and risks.

How much paternalism is too much paternalism? On one hand, we vaccinate against a wide variety of diseases without eliciting much worry of paternalism (at least, sidestepping debates over side effects of some current vaccines). In light of both subjective reports, a wealth of clinical evidence, and modern neural evidence, addiction has a significant neuropsychological disease aspect to it. Moreover, the economic costs of addiction can be readily estimated, both at the personal and societal level. Whether these costs are absorbed by the individual and thus also indirectly by society, or directly by society through a public health care system, they are a significant policy consideration. So, perhaps vaccines against drug use can be justified similarly to conventional vaccines.

Yet perhaps it is not surprising that conventional vaccines do not elicit the same level of concern over paternalism as anti-drug vaccines. Diseases like mumps or polio have virtually no redeeming benefits. The same cannot quite be said for a psychoactive drug that has abuse or addiction potential. Even the most harmful or addictive of such drugs has the potential to create a pleasurable experience, at least for a limited time. All have some potential, however slim, to be used in a very measured way with minimal harm and without addiction. A libertarian might say that every person has the right to choose to assume the risk of navigating that line for himself.

There are reflections here of disagreements over whether possession and use of some drugs ought to be criminalized. Many advocates call for decriminalization of some drugs. Some advocates even call for decriminalization of all or virtually all drugs. If they do so on libertarian grounds, they may see anti-drug vaccination in childhood as an even more extreme trampling of autonomy—whereas criminalization seeks to limit a person's liberty by deterrence, vaccination against a drug would impair the person's very ability to experience the drug. Thus, we can expect people with libertarian values to have serious misgivings about the use of anti-drug vaccines in childhood.

Debates of libertarian versus paternalistic principles could apply to the most dangerous drugs. But even without going so far, some drugs with abuse potential carry as well potential benefits that are not easily dismissed. Between the poles of the most dangerous drugs (e.g. methamphetamine) and the least dangerous drugs (e.g. coffee) there is a middle ground of drugs for which the cost-benefit balance is not black and white, at least for some users and for some extent of use.

The cost-benefit of a given drug, and thus of vaccinating against it, can depend on the user. Some users may respond physiologically to a given drug in unusual ways. To give an example at least in principle, there could be a minority of patients who respond unusually well to nicotine and unusually badly to first-line therapies for depression, cognitive impairments, or other mental illnesses. This could mean the cost-benefit of some nicotine use actually lines up for them, at least within a reasonable margin of personal or professional opinion. Such patient-specific information is generally unavailable if a vaccine is administered in childhood.

The cost-benefit of a drug is also informed by values, both cultural and personal. For example, many experts (and certainly many alcoholics) regard alcohol as one of the most devastating addictive drugs, yet in some respects it is valued as virtually a staple, at least in mainstream Western culture. In some cultures cigarettes are far from reviled despite common knowledge of their harm. Importantly, how a culture judges the cost-benefit of a given drug can readily shift in a person's lifetime—in Canada at least we continue to see such a shift with regard to marijuana. Thus, vaccinating against a certain drug in childhood could amount to making an irreversible decision for a person that will become obsolete in the context of future norms.

There is also the issue of personal values. Tobacco is a killer but to many people the occasional fine cigar is a beautiful thing in life. Some people find personal value in cannabis while others find none. Even “harder” drugs like hallucinogens can provide experiences that some people view as valuable, even as formative. Yet the values a person will hold with respect to a given drug are not known in childhood, and moreover are not necessarily the same as the values of his parents. Thus, important personal values are not available to inform a decision to vaccinate in childhood.

More philosophically, do we lose something when we short-circuit a person's temptations altogether? Perhaps some opportunity to build character, to grow from hard choices and harmful experiences? Something even deeper, along the lines of the philosophical conjecture that one cannot be said to be “good” if one never has any choice to be bad?

What about all the ways, both direct and indirect, that human achievement has been augmented by the ubiquity of psychoactive drugs? Or the many inspired works in various niches of creativity that have been possible in part due to drugs, even if sometimes at the cost of addiction and illness? By vaccinating away a psychoactive substance with a dark edge to it, do we replace these cultural silver linings with a clinical white whose only distinguishing virtue is that it is safer in the long term?

3. On the other hand...

How much meaningful autonomy are we really taking away if we vaccinate someone against a highly addictive drug? A person who is an addict or has been in some way harmed by a drug could well wish he had never used the drug at all. Although when he is born we cannot know whether as an adult he will find himself in this position, we may at least know there is a real chance of it. In this light, then, there is also a real chance that when we vaccinate in childhood we are protecting his autonomy in a wider perspective. Is this perspective the more meaningful one?

This is reminiscent of the story of Odysseus, who was curious to hear the fatal call of the Sirens as his ship sailed past and so ordered his sailors to tie him to the mast and not release him despite whatever orders he would give, while only they plugged their ears with beeswax. As expected, when the ship passed the Sirens Odysseus pleaded to be untied, but his sailors dutifully refused. In keeping him captive at his prospective command his sailors flaunted his autonomy at the moment but protected it in a wider sense. Of course, in the case of anti-drug vaccines it is the child's parents that weigh the risks and make the prospective command for him. Also, Odysseus was reasonably sure what the Sirens' effect would be and arguably that effect had no redeeming benefit worth considering. The Sirens are perhaps more similar to polio than to cocaine, moreover to polio that the child is certain to catch.

Some concerns with vaccination turn on modality, that it is altering a person's capacity to have certain experiences at a physiological level. Is this basis for concern a dualist double standard? For instance, education also permanently alters a person's capacity to have certain pleasurable experiences. While we judge education to be for the best, some small part of uneducated ignorance is also blissful ignorance. And education, like a vaccine, is an intervention that we force on children without their consent. Seen this way, how relevant really is the fact that an intervention takes the form of a vaccine?

Could we work around many of the concerns of paternalism if advances in technology allowed us to use childhood vaccination in more finely targeted ways—for example, by vaccinating only people who are at high risk of addiction in light of predispositions in their family, or even in light of evidence of predisposition at the neural level? What if advancements in screening technology brought enough precision that we could vaccinate only people for whom any exposure to the drug in question would almost certainly lead down a path of addiction? Would a libertarian ethic or the inherent value of self-actualization still prevail in those circumstances?